![Sample our Medicine, Dentistry, Nursing & Allied Health journals, sign in here to start your FREE access for 14 days]({"type":"image" , "src" : "/sda/5944/TOC-Subject-Sample-2021-Medicine-Dentistry-Nursing-Allied-Health.jpg"})
Abstract
The nature and role of the patient in biomedicine comprise issues central to bioethical inquiry. Given its developmental history grounded firmly in a backlash against 20th-century cases of egregious human subjects abuse, contemporary medical bioethics has come to rely on a fundamental assumption: the unit of care (and the unit of value) is the autonomous self-directing patient. In this article we examine first the structure of the feminist social critique of autonomy. Then we show that a parallel argument can be made against relational autonomy as well, demonstrating how this second concept of autonomy fails to take sufficiently into account an array of biological determinants, particularly those from microbial biology. Finally, in light of this biological critique, we question whether or to what extent any relevant and meaningful view of autonomy can be recovered in the contemporary landscape of bioethics.
Notes
1. There are, of course, several other types of criticisms at work. For instance, Joffe and colleagues demonstrated experimentally that patients tended to value a shared decision-making environment over one that normatively privileged a narrow account of autonomy as brute self-determination, further weakening the strong view of the concept (Joffe et al. Citation2003, 106–107).
2. Cf. McLeod and Sherwin (Citation2000, 250) on the role of oppression in interfering with a person's ability to act autonomously and Nedlesky (Citation2011, 53 and 176) on a nuanced conception of autonomy in similar cases.
3. This case offers further and more substantial biological evidence to developing views like that of Robert (Citation2006). Robert has argued that epigenesis, the interaction between internal genomic processes and external environments, is constitutive not only of genes (xv and 74) but also of environments themselves. Robert concludes, “It is evident not only that organisms construct themselves within environments but also that they help to construct their environments” (87).
4. The 10:1 ratio of cells is a factoid still promoted on the Human Microbiome Project website. In reality, we are close to a 2.5:1 ratio since human organisms consists of about 40 trillions human cells and the microbial cells constituting our microbiome consist of around 100 trillions cells (Ravel et al. Citation2014). Recently, even the 2.5:1 ratio has been called into question (Abbott 2016). Thanks to Brendan Bohannan for this point of clarification.
5. Lorraine Code's book (Citation2006) is certainly the closest in nature with the view we espouse in this article. However, we still believe that there are some significant differences between Code's usage of the concept of ecology and our ecological conception of the human organism. As we note earlier, she employs ecological thinking both literally and metaphorically (51). Our distance from Code's Ecological Thinking emerges when we point out that it is the literal and not the metaphorical view that suffices to unsettle the idea that human beings could be understood in isolation, as some form of physiological and epistemic islands. An updated and more complete ecological view of human organisms pushes away from a mere metaphorical reading of ecology and toward a robust literal view.
6. Epigenetics might be another example of a similarly overlooked influence on individuality and autonomy; see Paul Hurd (Citation2010).
7. In addition, recent literature from moral psychology and cognitive science has profoundly impacted the possibility for robustly autonomous decisions, denying a sharp line between psychological and biological perspectives. Whether we think of dual-system or dual-process theories of the mind (Bargh Citation1999; Smith & Collins Citation2009) or of implicit bias views of human agency (Banaji and Greenwald Citation2013), those views reject the rationalistic picture of human agency and highlight the very significant role of unconscious biases in our behavior (Haidt Citation2012).
8. There are interesting questions that remain to be asked about the relationship between our view and a view of collective agency/autonomy of corporations from a legal perspective. We believe that a collective agency view, like that of Philip Pettit (Citation2011), relies heavily on a coherent set of shared preferences/values, which our microbial ecosystemic view might call into question. Thanks to Arthur Caplan for bringing this future angle of inquiry to our attention.
9. We think that this novel view of patient-centered care also blurs some conceptual and disciplinary boundaries between patient care and public health.